The Obama administration announced immigration detention reforms in 2009, primarily in response to sustained criticism over medical neglect and unnecessary deaths of immigrants in detention. This report analyzes government death reviews and inspection documents, which show that problems persist, inadequate medical care continues to contribute to the death of immigrants in federal immigration custody and U.S. Immigration and Customs Enforcement’s (ICE) ineffective inspection process has not improved the quality of medical care.

Egregious violations of ICE medical care standards played a prominent role in eight in-custody deaths from 2010 to 2012. Fatal Neglect: How ICE Ignores Deaths in Detention, a report jointly produced by the American Civil Liberties Union (ACLU), Detention Watch Network (DWN), and National Immigrant Justice Center (NIJC), examines these deaths and the agency’s response to them. Our research shows that even though ICE conducted reviews that identified violations of medical standards as contributing factors in these deaths, routine ICE detention facility inspections before and after the deaths failed to acknowledge—or at times dismissed—these violations. Instead of forcing changes in culture, systems, and processes that could reduce future deaths, ICE’s deficient inspections system essentially swept the agency’s own death review findings under the rug.

In the case of Pablo Gracida-Conte, who was detained at Arizona’s Eloy Detention Center, ICE’s death review concluded that his death “might have been prevented” if he had received “the appropriate medical treatment in a timely manner.” The ICE death review also found that Eloy had been operating without a clinical director for years, the medical clinic was understaffed, and Eloy’s doctor reported that she “badly needs help.” Nevertheless, routine ICE inspections both before and after Mr. Gracida’s death concluded that medical staffing was adequate. Indeed, an inspection after Mr. Gracida’s death claimed that his was the first “to ever occur” at Eloy when, in fact, it was the facility’s 10th death. The findings in Fatal Neglect: How ICE Ignores Deaths in Detention underscore how ICE’s deficient inspections system, first exposed by DWN and NIJC in the October 2015 report Lives in Peril, exacts a tragic human toll.